Healthcare Provider Details

I. General information

NPI: 1134846066
Provider Name (Legal Business Name): MATRIX SPINE AND SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SW 12TH AVE STE 440
POMPANO BEACH FL
33069-3200
US

IV. Provider business mailing address

43 S POWERLINE RD STE 245
POMPANO BEACH FL
33069-3001
US

V. Phone/Fax

Practice location:
  • Phone: 954-228-8486
  • Fax: 954-228-2601
Mailing address:
  • Phone: 954-228-8486
  • Fax: 954-228-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. DENNIS BONNEAU
Title or Position: MEMBER MANAGER
Credential: CH
Phone: 954-228-8486